The Appellate Term for the 2nd and 11th Judicial Districts has reversed the Civil Court's ruling in West Tremont v. GEICO and has held that the statutory requirement that health care expenses be necessary applies to claims for MRI testing.
Long Island Radiology v. Allstate Ins. Co. The Appellate Division, Second Department held that an insurer may raise lack of medical necessity as a basis for denying claim for reimbursements to radiologists seeking payment for MRIs pursuant to prescriptions thus reversing the lower Court. Since the defense of lack of medical necessity may be raised by insurers against injured parties it is also available against a party that accepts an assignment of no-fault benefits. This decision follows the holding by the Appellate Term in West Tremont v. Geico.
Stephen Fogel Psychological, P.C. v. Progressive Cas. Ins. Co. The Appellate Division, Second Department held that appearance at an IME by a claimant is required whether the insurance company demands the IME before the claim form is submitted or after the claim form is submitted. The Appellate Term on the same case had created a distinction between claims depending on when they were submitted in relation to the failure to of the claimant to appear holding that if the failure was before the submission of the claim forms it would simply shift the burden on medical necessity to the Plaintiff. The Appellate Division held that appearance at an IME is a condition precedent to coverage under a policy and as a result an insurer may deny a claim retroactively to the date of loss for a claimant's failure to attend IMEs.
A.B. Medical Services v GEICO The Appellate Division, Second Department reversed the Appellate Term and held that an insurer need not summarize its peer review or IME in its denial or set forth a medical rationale for nonpayment. Since the regulations provide that an applicant may receive a copy of the peer review or IME upon request, it is enough for the insurer to refer to such peer review or IME in its denial. To the same effect were the companion cases decided the same day New York Univ. Hosp. Rusk Inst. v GEICO and A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co.